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Pathology report in - should we commend with HT?

Pathfinder
Posts: 55
Joined: Jun 2016

 

*THREAD TITLE ADJUSTED 16/8 - Surgery was performed on this day, and related questions are further down the thread.

****************************

Hi all,

New to the board and desperate for your knowledge. 

My Father in law has been diagnosed with PC, result of the biopsy is Gleason 8 and his PSA is 24. Based on his medical records the PSA appears to be doubling yearly (don't ask why this wasn't addressed earlier, it's not a nice story!).

His bone scans and MRI came back negative for mestastatis, and he has no symptoms.

From all of my research it seems to me like surgery ASAP is the best option. We're all extremely worried about the cancer being aggressive based on the numbers and don't want to give it time to breach the prostate.

However the doctor has reccommend three months of hormone treatment first, including a monthly injection and pills to diminish testosterone. I understand that the reccommendation is based on making the surgery safer, however as the PSA is doubling yearly at a rate of almost 1 a month, that seems like a long time to wait.

And here's the serious part: He's in China. Chinese hospitals are fairly dark. If they can make an extra 10,000 in treatments prior to the surgery, they probably will regardless of his biopsy results. This is the main reason why we're seeking a second (or third) opinion (this week), but I'm fairly wary of the reliability of the system here from experiences passed down by other people.

I hope you can help. If I sound frantic, I am! I feel as though this is a race against time and I'm not comfortable with his biopsy numbers at all. If someone can give me any advice regarding how 3 months of hormone therapy would benefit the surgery, how it works exactly (does it actually stop cancer cell growth, or reduce its size making it easier to catch-all with prostate extraction?) I would appreciate any information you have.

Thank you so much for taking the time to read this.

 

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3228
Joined: May 2012

Pathfinder,

Others here are much better informed in aggressive and advanced treatments, but I have read that a Gleason of 8 is ordinarily ASSUMED to have escaped the gland. It constitutes very aggressive disease. 

Many doctors, when treating aggressive cancer that has escaped, would recommend that prostectomy not be done at all, now or later. The argument ""for" surgery is toward debulking, the argument "against" is that RPt will not remove all of the disease, and the side-effects are more dibilitating for the patient than they are worth.

He probably needs to be more precisely staged, which would require advanced imaging that perhaps is or is not readily available in China.    Regardless, beginning with HT does not seem unreasonable to me, but as I said, I am not well versed in aggressive or late-stage treatments given first-line.

Do get the additonal opinions.

max

hopeful and opt...
Posts: 2218
Joined: Apr 2009

Prostate Cancer is a very slow growing disease, so it best for your father in-law to make an educated decision and not panic as you are. It is counter productive.

Max gave excellent advice.

What is the patients age? Surgery can have major side effects, the older one is the more likely the side effects 

How many cores were taken. Of these how many were positive. What was the Gleason of these positive cores. What percent of each Core was positive. 

 

Many men with a Gleason eight, first have hormone treatment. The results of radiation treatment is Better when radiation follows hormone. In addition radiation treatment includes a greater range outside the Prostate do there is a better chance of cure.

 

Keep on asking questions, we can help.

hopeful and opt...
Posts: 2218
Joined: Apr 2009

Prostate Cancer is a very slow growing disease, so it best for your father in-law to make an educated decision and not panic as you are. It is counter productive.

Max gave excellent advice.

What is the patients age? Surgery can have major side effects, the older one is the more likely the side effects 

How many cores were taken. Of these how many were positive. What was the Gleason of these positive cores. What percent of each Core was positive. 

 

Many men with a Gleason eight, first have hormone treatment. The results of radiation treatment is Better when radiation follows hormone. In addition radiation treatment includes a greater range outside the Prostate so there is a better chance of cure.

 

Keep on asking questions, we can help.

Will Doran
Posts: 207
Joined: Sep 2015

Pathfinder,

So very sorry to hear of your father-in-laws situation.  What you are saying is the reverse of what was recommended for me.  I was diagnosed with a PSA of 69, Gleason 7, I had no symptoms, at the age of 67. I had no metastatis, but post surgery pathology showed one very small spot in one lymph node ( that spot didn't show up on my MRI's because it was so small).   I had Robotic Assisted  Surgery in Dec 2013.  Followed by two years of Hormone Therapy (Lupron) and I had 8 weeks of radiation, after I was on the Lupron for 4 months.  It was done that way so the Lupron would weaken any remaining cancer cells that might have remained in the cavity so the radiation could kill those remaining cells. I was a very high end Stage 3, aggresive, and they treated me as I was an advanced Stage 4.   My PSA dropped to <0.010 in 2 months, post surgery, and has remained there ever since (as of check up last month).  I am off the Lupron and have been for 5 months.  My testosterone has come back up a little bit ( from 17, at it's lowest, to 134, which is still very low--normal is 250 to 1,100).  I have another check up with blood work in September.  I was given the option of doing all radiation treatment with radioactive seeds, But I wanted the cancer removed ASAP.  So, I understand your concern.  All of our cases are different, so what has worked for me (so far) might not be what is needed in your Father-in-law's case.  However I would strongly recommend that you get other opinions.  Study up on all of the side effects of these drugs/chemo, the side effects of the surgery, and all other treatments that will be needed.  Make sure you have all the information you can get so you and your Father-in-law can make an educated decision.

Good Luck

Know that your family is in my thoughts and prayers.

Peace and God Bless

Will

Pathfinder
Posts: 55
Joined: Jun 2016

Hi guys,

I appreciate your responses!

"Prostate Cancer is a very slow growing disease, so it best for your father in-law to make an educated decision and not panic as you are. It is counter productive."

My worry about time is related to what I know about PSA velocity, in that the doubling speed seems very fast (yearly). Coupled with the biopsy result, I feel under pressure to figure out the right course of action sooner rather than later. :(

"Others here are much better informed in aggressive and advanced treatments, but I have read that a Gleason of 8 is ordinarily ASSUMED to have escaped the gland. It constitutes very aggressive disease."

That's very worrying. The doctors said they thought that it was still contained at the moment, however I don't know how they came to that assessment exactly. It's hard to get details here and I can't talk to them directly owing to the language barrier. You say 8 is assumed to have moved outside the gland - is that a guarantee?

"What is the patients age?" "How many cores were taken. Of these how many were positive."

He is 63, I believe they took 14 cores but I don't have the papers right now, I will get the information for you ASAP. I just know that the Gleason scores for the different positive cores varied, some were 8, others lower than 8. I believe the average is 8.

"Many men with a Gleason eight, first have hormone treatment. The results of radiation treatment is Better when radiation follows hormone. In addition radiation treatment includes a greater range outside the Prostate so there is a better chance of cure."

What kind of radiation treatment are we talking about? Is it something that is localised to the prostate area, or full chemotherapy? 

Thank you again for all of your help!

 

 

S

Old Salt
Posts: 720
Joined: Aug 2014

The above is just my opinion of course. But medically I am not too far removed from your father-in-law because my cancer was organ confined but with a higher (Gleason 9) score.

The argument for a course of radiation is detailed in the response of 'hopeful and optimistic'. And as he wrote, hormone treatment should be on top of that. The latter will likely lead to the killing of cancer cells that might have escaped the prostate and will also kill cancer within the prostate. Starting out with hormone therapy in advance of radiation is standard procedure AFAIK. The reason being that the hormone therapy will make the radiation more effective (I see that 'hopeful' made a similar statement). 

I realize that I am writing from a US perspective, and your father-in-law will have to deal with Chinese doctors and practices about which I know nothing.

Please note that chemotherapy is an entirely different treatment, not appropriate at this time.

As others have stated, take your time and study all the options.

PS: Gleason 8 cancer cells may or may not have escaped the prostate; the imaging studies showed that no major metastasis has taken place, which is encouraging.

VascodaGama's picture
VascodaGama
Posts: 2958
Joined: Nov 2010

Pathfinder,

From the comments and info you share it seems that you are suspicious of his doctor’s suggestion. I agree that the combination therapy made of HT plus Surgery is weird but it could be suggested due to a reason you have not at hand. For instance, if your family in China has requested for early means of intervention to hold the advancement of the cancer while deciding on a treatment (They may have adopted this to gain time for receiving your comment from the USA); or if his gland is too big in size that would not be feaseble for radiation or earlier surgery intervention; etc.

My opinion is that his case is not at the verge of becoming a night mare overnight. The high PSA of 24 signify the presence of a voluminous cancer (producing the serum) which could be composed of several independent tiny colonies of tumors of different Gleason patterns that could be contained in the gland or already have spread. It is a fact that aggressive Gleason patterns of 4 and 5 are commonly found in cases of extra prostatic extensions, but according to the biopsy info you provided, lower Gleason exists which could be the ones producing the high levels of PSA. Gleason 8 cancers are more for the type of cells that produce lesser amounts of PSA.

I wonder about the Clinical stage his doctor has provided. This typically provides a clue on the data they have in hands. Was there any image study (MRI, CT, bone scan, x-ray, etc). Do you have any report?

Physicians are aware of the limitations in these exams that quite often provide false negatives but when classifying a case they would not disregard the data collected. They tend to follow the guidelines provided by their association (Urology, radiology, oncology, etc), and only a few number follow their instincts based on past experiences. Naturally, a urologist most probably would recommend surgery as much as a radiologist would recommend radiotherapy.

I would think that his doctor is following his trade principles. The suggestion for the HT (hormonal treatment) may have nothing to do with the surgery. In any case, when the prostate size is too big some surgeons (in particular those performing robot assisted surgery=Davinci) recommend diminishing the size of the gland firstly (with hormonal drugs), before operating on it. Robotic surgeries use small holes so that big glands could not be take out into one piece, it should be cut inside the abdomen which procedure raises the probability of leaving behind a tiny piece of “contaminated” tissue (microscopic) that could later cause recurrence.
Such could be his argument of “… making the surgery safer”, as you describe in your post above.

I agree that waiting would be better, even in spite of the risky doubling, if surgery is found to be the best choice, but is it surgery the only and better way to treat this patient? There are other options to be checked about.

One note regarding the hormonal treatment is that this is palliative and does not cure. It manages to pin down the cancer so that the PSA gets lower; however, a lower PSA due to hormonal manipulations masks the results/outcomes of a radical treatment. Accordingly, the success of the surgery done while on the effects of the hormonal therapy cannot be verified at once. One should wait till the effect vanishes, taking about 6 months after the end of the effectiveness of the HT drug.

You doing it well in getting second opinions but you should have in hand a copy of all tests and exams so that proper advice is obtained.

Best wishes,

VGama

 

hopeful and opt...
Posts: 2218
Joined: Apr 2009

The PSA is an indicator only  , there are various factors before a blood draw that affect PSA such as exercise bike riding or even a hard stool. The the pathology results from a biopsy is the critical information of which you have requested. It is also important to look at the written results from the MRI. There are different MRI machines some better than others if the MRI machine used a 1.5 or 3.0 Tesla magnet

As far as finding out about radiation it is best  to interview a radiation oncologist who would be knowledgeable and would administer the various radiation technology such as imrt and the variations of this technology as well as sbrt

Will Doran
Posts: 207
Joined: Sep 2015

Pathfinder,

As Hopeful & Optomistic stated, things like bike seats will raise PSA.  I was a road cyclist and was on a bike seat up to three hours per day, riding with the Penn State cycling club, at times..  I had a PSA that showed 1/2 point above what was acceptable.  I had  DRE and was told that my prostate was "the smallest prostate" the doctor had ever examined.  He wanted to do a biopsy, but my GP said it was all from the bike seat and therefore didn't recommend doing the biopsy, since my prostate was so small. So there were no real signs of a problem.  I had no symptoms.   However 5 years later I had a PSA of 69.  If only I had done the biopsy 5 years earlier.  But that's the way it goes.  My cancer was found, by sort of accident, when I had an internal bleed and it showed up in blood work and MRI's.  At that point my prostate showed up bright red in the MRI (with contrast imaging) pictures.  So, we proceeded.  So as stated it's very important to look at all kinds of tests and the results. 

Now, with the prostate gone, I'm on a spinner bike for 80 - 100 minutes per day and all is well (so far).

Good luck

Peace and God Bless

Will

Pathfinder
Posts: 55
Joined: Jun 2016

Guys, you're all really wonderful, I didn't realise I would receive such fantastic help here. You're helping to calm my nerves somewhat.

I'll try to make the biopsy information as clear as possible: the entire report is in Chinese. I can speak some, but can read none. However I can identify the PSA and the Gleason scoring, which has various numbers. I believe the number of cores taken were 12. However I'm holding out for someone here to get me the full breakdown so I can share it with you in detail. 

For now, I'll tell you what I do know.

The doctor has prescribed the following:

- 1 Bicalutamide tablet daily

- 1 injection a month of Zoladex (produced in the UK)

The doctor has reccommended:

- Neoadjuvant chemotherapy prior to surgery

Regarding the additional scans:

- As far as I know there is no sign of metastatis from the bone scans/MRI

Doctors comment:

- They don't "think" the cancer has left the prostate. 

- They wany to do HT for 3 months before surgery

Now some of this is dubious for me. We've not been able to have a doctor sit down and actually explain the test results and plan of action in detail. I haven't seen evidence (or what they believe is evidence) that the cancer hasn't moved outside of the prostate for example. I feel as though it's difficult here to get detailed answers, and it's disturbing when you're trying to figure out a plan of action.

"Accordingly, the success of the surgery done while on the effects of the hormonal therapy cannot be verified at once."

That's actually one of the questions I had, whether there was any effect of the HT on surgery, thank you for that. 

I'm already aware of the way PSA levels can be affected by things like bike riding, we're just concerned at the yearly doubling rate. 

We have some concerns also about the Bicalutamide, as apparently it can adversely affect the liver. Does anyone know about abiraterone? Apparently it's a breakthrough in Prostate cancer treatments, and has become available in China in 2016. We're not sure how to locate it just yet.

We have an appointment for a second opinion tomorrow with a fairly reputable hospitable, I'll get back to you with any information I have!

Thanks to you all for your support!

 

Pathfinder
Posts: 55
Joined: Jun 2016

Ok, the translation has been very difficult, and we did our best! I hope some of this makes sense to you guys and you can help to explain some of it. We checked the MRI info and it does say negative for metastases, that's all we know regarding that currently. Here is the translation of the biopsy findings:

(Left apex medial, left apex lateral, right apex medial, right apex lateral, right mid lateral) Benign prostatic hyperplasia, in glands and smooth muscle hyperplasia. 

(Left mid medial, right bottom medial, right bottom lateral, 14 left nodule) Benign prostatic hyperplasia, in glands and smooth muscle hyperplasia. 

(Left mid lateral) Prostate cancer. Gleason score 5+3=8 (10)  (ISUP Grade 4) Tumor cells: P504S+, CK34bE12-, P63-, Ki-67 Positive 8%. 

(Right mid medial) Benign prostatic hyperplasia, in glands and smooth muscle hyperplasia. Epithelial cells: P504S-, Ki-67 positive 3-5%; Basal cell: P63+, CK34bE12+. 

(Left bottom medial) Prostate cancer. Gleason score 3+3=6 (10)  (ISUP Grade 1) Tumor cells: P504S+, CK34be12-, P63-, Ki-67 Positive 8%. 

(Left bottom lateral) Prostate cancer. Gleason score  4+3=7 (10)  (ISUP Grade 3) Tumor cells: P504S+, CK34bE12-, P63-, Ki-67 Positive 8%. 

(13 left nodule) prostate cancer. Gleason score 3+5=8 (10)  (ISUP Grade 4) Tumor cell: P504S+, CK34bE12-, P63-, Ki-67 positive 8%, PSA+. 

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3228
Joined: May 2012

These biopsy specifics will assit the guys, Pathfinder.

You asked if a Gleason of 8 guarantees that PCa has escaped the gland. Absolutely not ! It is probable but not assured, but if forced to assume one or the other, assuming that it has is safer than assuming that it has not. To repeat: what he most needs is more precise imaging, if available. But no diagnostic tool or imagining ever guarantees anything in cancer treatments. There are no warranties, and you never get your money back.

Vasco made the important observation that HT is not curative. Be aware that what is curative of PCa (when they are successful) is surgical removal or radiation (or a combination of both). 

Somewhat at random I would add that against PCa chemo also is palliative only, unlike most other cancers, against which chemo isnoften potentially curative, especially against early-stage disease.

It seems the many contributions submitted here are helping your decision making process move forward in a timely manner.

VascodaGama's picture
VascodaGama
Posts: 2958
Joined: Nov 2010

It is disturbing indeed when doctors do not explain details or pass over the data at their hands. I do understand that they are not teachers and we (the pupils) should get educated on the illness before visiting them. Preparing a “list of questions to the doctor” in advance of each consultation is reasonable.

In the descriptions above, one missing piece of data is the size of the prostate (it should be written in the MRI report or Biopsy), in any case, your indication of existing hyperplasia (“..Benign prostatic hyperplasia, in glands and smooth muscle hyperplasia..”), leads to think that your Father-in-law could have a larger than normal gland. Larger sizes glands and Hyperplasia also justify existing high PSA of which a greater portion may be produced by benign cells.

The term “smooth muscle hyperplasia” may signify PIN (prostatic intraepithelial neoplasia). They do not make any reference to the matter so that we wouldn’t judge it as high grade PIN, which would turn the case more aggressive, with the right side of the gland involved. The other information regards the cancer in the left side with Gleason pattern 5 found in two cores 8% each. They do not comment on a tertiary grade so that the score 8 (3+5) stands. From the data shared, his clinical stage is T2b but the PIN on the right side could upgrade it to T2c. The grade 5 provides the possibility for a T3a.

I wonder about another comment pointed by you that the doctor has recommended “Neoadjuvant chemotherapy prior to surgery “. Does he recommend chemotherapy or hormonal therapy?
Chemo and hormonal are two different treatments. Isn’t it a mere translation mistake?

Bicalutamide (Casodex) and Zoladex (LHRH agonist similar to Lupron) are traditional hormonal drugs. Abiraterone (Zytiga) is also a drug of the hormonal arsenal, usually taken as a second-line drug when the patient becomes refractory to the initial HT drugs. I wonder if his doctor has recommended chemotherapy instead of the hormonal, but either way, both would be meaningless for an adjuvant surgery approach.
One note goes to the possibility that his doctor is running a clinical trial similar to the one run at USA, below. Participants in trials have usually free treatment. You should investigate if he has been offered the inclusion;

https://clinicaltrials.gov/ct2/show/NCT00002633

Max above says it all. Give preferences to a radical therapy (surgery or radiation) and add a palliative that may improve the primer. In such aspect, radiation (RT) seems proper when the case includes information regarding high risk for metastases.

Here are some reading materials that may help you:

A compendium on Prostate cancer and care;
http://www.lef.org/Protocols/Cancer/Prostate-Cancer-Prevention/Page-01

Booklet about biopsy;

http://www.harvardprostateknowledge.org/understanding-your-prostate-pathology-report

Please note that I have no medical enrolment. I have a keen interest and enthusiasm in anything related to prostate cancer, which took me into researching and studying the matter since 2000 when I become a survivor and continuing patient.

 

Best wishes,

VGama

 

Pathfinder
Posts: 55
Joined: Jun 2016

Thank you for your responses.

Indeed it's difficult to find a doctor patient enough to give us clear details so we know what we're facing.

Regarding prostate enlargement, we were told it is enlarged, but not significantly so.

VGama, would you mind explaining a few things to me? I'm not 100% on the medical lexicon.

From the readings, does it say cancer is present on both sides of the prostate? Or hyperplasia is on one side and cancer on the other? 

Does this case appear to be high risk for metastases in your opinion? Would you mind explaining what PIN constitutes exactly, and what T2b, T2c or T3a would mean in terms of risk and appropriate action?

I understand RT seems appropriate at this stage, but is this all pointing to surgery as the wisest option?

Today we got a second opinion with an equally impatient doctor, and the only valuable insight we received is that if the HT successfully reduces the PSA after a month, it is possible to have surgery at that point, rather than waiting 3 months.

Thank you again for your help.

VascodaGama's picture
VascodaGama
Posts: 2958
Joined: Nov 2010

Path,

From the info you have shared, I cannot understand the reason for doctors at that hospital recommending hormonal therapy before surgery. They seem to be out of focus, treating the PSA not the cancer.
The biopsy report indicates cancer in left lobe and benign tissue in the right. Hyperplasia may exist allover. The number of positive cores is not well specified but one could think that only a fewer percentage involves Gleason pattern 5. You can request a second opinion on the biopsy slides from another pathologist laboratory. You could request your family to DHL them to you and then send it to JH laboratory for an opinion on the findings.

Regarding the treatment, surgery is recommended to contained cases (the whole cancer inside the gland). This is what surgery does, dissect the whole gland. Radiation can also treat at the same level as the surgery to a contained case but it can also cover a wider field including the gland, its bed and the localized lymph nodes. Radiation, therefore, is better when one has doubts about the location of the cancer. 

The hormonal treatment can be done any time. It is paliative so that it only controls the advancement of the cancer. Three months HT is too short for any significant benefit. Usually HT treatments are done for 18 months or just 6 months when its purposes are to "improve" the results of the prime radiation treatment.

You can find details of my comments googling the senrtences.

Best wishes,

VG

Pathfinder
Posts: 55
Joined: Jun 2016

Well, one of my first questions was why 3 months HT before surgery, and the fact you're querying it is encouraging. We were told something to the effect of "HT will reduce the size of the tumours/cancer making the chance of surgery more successful". Whereas the 2nd opinion doctor yesterday said a month may be enough. He said if the PSA falls after a month of HT then you don't need to wait for surgery.

Is the suggestion that HT will 'reduce the cancer's size' to make surgery more effective incorrect then? Because this is what we were lead to believe. 

If that isn't the case, I think we should start looking for a reputable surgeon to act ASAP, however I am aware there are a few types of prostate cancer surgery available: the traditional one, which requires opening up the patient (I'm told this allows the doctor to see more, but the surgery is more traumatic), another kind that is less invasive but the doctor has less visibility, and robot surgery, of which I'm still reading about the details. Are any of these more effective in terms of results than another?

Thanks again!

 

hopeful and opt...
Posts: 2218
Joined: Apr 2009

The side effects from surgery are severe more so than other active treatment types. Additionally surgery is a localized treatment. So if the cancer has  escaped the prostate, of which there is there is a good chance of in your father's case the cancet will still exist and and salvage radiation treatment will be required. The side effects of each of these treatments are cumulative.

Hormone treatment before radiation increases the success rate of the radiation. 

 

 

 still exist.

That is why radiation would be preferred treatment and your father's case. Not only will the prostate be treated but the surrounding areas around the prostate will be treated. It is more likely that they will be better treatment success with less side effects

Having hormone therapy before radiation increases the effectiveness of the radiation

 

Pathfinder
Posts: 55
Joined: Jun 2016

The initial MRI scan was done on a T1.5, however we have located a T3.0 as suggested here. To be clear, we are asking for another scan for bone metastases and to examine the prostate to see if cancer has escaped the gland - is this correct?

We know that surgery has major side affects, but the dilemma remains: if the cancer hasn't escaped the gland then surgery is the best option and we need to act fast. We were told by the first hospital who performed the biopsy + tests that it hasn't escaped the gland. But here most people suggest that it probably has. 

I know there's no way to be 100% sure, even with hospital examinations, but if we do a second scan with the T3.0 and they still believe the cancer is contained, would that be a good reason to go for surgery.

Or should we just skip all this and go for radiation therapy post a few months of HT.

Sorry, this really is a dilemma :(

CowboyBob
Posts: 31
Joined: Oct 2013

I think you are not "hearing" what the members of this forum are telling you.  I don't believe anyone here has suggested they believe surgey is the best treatment for your father. On the contrary, posters have tried to warn you that the complications of surgery are significant and worse than radiation therapy. Although I think your father's workup is incomplete, it is my understanding that his survival rate with radition will be similar to his survival rate with surgery and the side effects significantly less. Outside of a study, I don't know why a doctor would administer chemotherapy for your father. 

 

I am afraid this is a bit like Mark twain's quote: "To a man with a hammer, everything looks like a nail that needs pounding"  Your father seems to be consulting with surgeons. It's not surprising they are recommending surgery.

If this was my father and with the information I understand of his case, I would be pushing hard to stay away from surgery at all costs.  I would strongly recommend he seek a second opinion from a qualified Radiation Oncologist (in Hong Kong or Singapore if necessary). Please don't push for surgery without understanding the facts

edited to correct some typos

Pathfinder
Posts: 55
Joined: Jun 2016

That's extremely helpful, thank you for putting that in perspective! I have indeed been focussed on surgery because I understood from various things I had read that if the cancer was contained within the prostate then surgery was advised. I will consult with the family regarding your post, much appreciated.

VascodaGama's picture
VascodaGama
Posts: 2958
Joined: Nov 2010

We all confront the same dilemma at front. Which therapy is the best to treat?

In the end, the one we chosen is the best. Though, you need courage to find that ultimate comfort for deciding.

Cowboybob is correct. Nobody here has “invited” you to choose surgery. It seems that the family in China has set their minds in surgery and given you the task in proving that such is in fact the best. You are looking for a decision and now worried that your comment against the initial thoughts are unaccepted, or even worse, not proper. You feel responsible.

As commented above, his status would not alter if the treatment (surgery or radiation) is done in three months. The cancer would not “runaway”, it will be there to get the blow when that is done (now or in three months). In such regards, the Tesla 3 MRI result could be your trigger threshold to start the treatment. This is acting fast. You do not need to rush anything.

3T MRI is more reliable as image study. You can request for them in China to include measurement of the gland. You also can request them to provide the results on a CD/DVD which copy you can use in the USA (at a PCa specialist radiologist) to obtain a second opinion. This is your great chance to feel accomplished and to get a REAL decision.

Back to the year 2000, in my times, surgery used to be considered the golden standard of treatment for prostate cancer. At present times such is not correct. The newer RT equipment and modalities can provide results at the same level, to reach the ultimate goal of cure. The choice is now done regarding the details of patient status. The risks and the side effects from treatment are different and that also contribute in the final decision. Incontinence and Erection dysfunction (ED) are prevalent in surgery interventions. Radiation is more linked to colitis, proctitis, libido and damage to semen. Both may prohibit fathering a child.
These should be at the choice of the patient not at the decision of family members.

Just for your information:
Surgery is done open (the traditional) taking approximately 5 hours and requiring blood transfusion; The robotic is faster taking approximately two hours; A similar modality not using a robot is the Laparoscopic done by experienced surgeons but both are more linked to incontinence cases. Radiation is administered from outside non invasive using special equipment that can differ in dose modalities (large dose at many fractions: IMRT or fewer number of fractions hyper fractionated: Cyber Knife); Invasive modalities include Brachytherapy (localized seeds implanted) and High Dose Brachytherapy (with radiation rods).
In contained cases, CK has the best performance status. For localized cases IMRT delivers better outcomes. RT can also be done in combination; eg: CK+IMRT or Brachy + IMRT, etc

The prostate gland is considered too large for surgery or radiation when that extrudes into the bladder. This is accompanied of problems in urination (difficulty, pain, frequency, etc), so that surgeons prefer to do TURP instead of removing the whole gland. The normal size is approximately 30cc but many do surgery when this is 50cc. Some guys have glands at the 80 cc level and still manage to be treated. Hormonal therapy to reduce the size of a gland is done over six months, and even that will not assure a significant reduction in size. HT leads to a reduction of the PSA starting approximately 1.5 months from the first injection of a LHRH agonist. Castration is seen at the two weeks point but the body takes another two weeks (or more) to clean circulating serum. The comment of his Interim doctor makes no sense.

VGama

 

Pathfinder
Posts: 55
Joined: Jun 2016

Wow, this is really helpful.

To put things in perspective from this side, it hasn't been anyone's decision to chase surgery per se, we're just only now becoming educated in what we're facing. The issue is that the doctor post biopsy instructed us that there would be 3 months HT prior to surgery. When questioned has the cancer left the gland, the answer was "we don't believe so", and all this based on a Tesla 1.5 MRI and the biopsy results posted above. That and an incredible vagueness when it came to the details of the condition where staging was concerned.

I suppose what we thought was, if the cancer is indeed contained within the gland, surgical removal of said gland is the most practical step. And because we're worried about the PSA doubling rate and aggressiveness of the cancer, we are trying to quickly figure out if this surgery can be done sooner rather than later.

However talking to you guys has been both educational, and in a nice way, provided an additional dilemma! Because nobody here told us Gleason 8 is "assumed" to have left the gland, and indeed they told us they believe in this case that that hasn't happened.

However we are all aware of the risks involved in surgery. We know nobody can make this decision for my father in-law. If radiation therapy is the better option for him, we will explain that in full.

Here's the thing that I didn't understand previously:

"The newer RT equipment and modalities can provide results at the same level, to reach the ultimate goal of cure."

We were under the impression that there couldn't actually be a cure with radiation therapy! We were thinking that by choosing RT over surgery it would simply be a case of fighting until the very end through a variety of treatments.

We kind of saw it this way: based on the information given here (Gleason 8 = likelyhood of leaving the gland) that surgery would have a 20% success rate of removing all the cancer, and an 80% chance of failure due to cancer having escaped. The 20% would be a cure, and that's the gamble.

We thought RT and HT would be less damaging in terms of side effects, but would only control rather than destroy the cancer. Kind of like extending life expectancy, but conceding to defeat eventually.

If RT can actually cure PC, then we need to reassess everything.

I'm really sorry if this sounds uneducated! We are learning as fast as we can, and there's a lot of ground to cover. The biggest issue has been not being able to understand the seriousness of my Father in-law's PC. We don't know the definite stage, we don't definitely know if it's contained in the gland, and up to now, we're not sure when and how to act regarding treatment options. It's often frustrating and generally concerning.

We will begin looking into the details of RT over surgery now, but if anyone has any more input, every little helps, because I'm getting more from you than I think I ever will from the domestic doctors here.

Thanks again for your support!

Swingshiftworker
Posts: 1013
Joined: Mar 2010

It's hard to talk about a "cure" for any cancer because there's always a chance of recurrence regardless of the method of treatment used -- be it surgery or radiation -- BUT there have been many men (me, included) who have achieved total remission of their prostate cancer by means of radiation treatment.

My situation was much different than your father's.  I had an early stage cancer w/only a Gleason 6.  There was no doubt that the cancer was fully contained and I was treated with a method called CyberKnife which is a form of SBRT - stereotactic body radiation therapy.  It is the MOST precise and accurate method of radiation delivery currently available.  It is not only used to treat prostate cancer but is also used for brain, lung, liver and spinal cord, where precision is especially needed and where surgery would be a much more detrimental alternative.

Given that your father's cancer is at Gleason 8 and no one knows for certain whether it has spread beyond the prostate, it is not clear that CyberKnife would be the better choice of radiation treatment BUT if the location of the cancer can be specifically determined through the use of a MRSI (magnetic resonance spectroscopic imaging), which is a specialized version of an MRI that pinpoints the location of choline (which is a marker for cancer) in the body, CK (or any other means of radiation delivery, such as IMRT which is more commonly available) should be very effective in entirely eliminating the cancer w/o need for surgery.

PS: You say that you are fully aware of the risks of prostate surgery but you don't say exactly what you know.  The risks of prostate surgery are not just those common to surgery -- like the risk of infection.  The risks of prostate surgery for a man are MUCH greater than that.  There is the risk of impotence (no erections) and urinary incontinence (have to wear a diaper) which is generally temporary (usually 1 year) BUT can become PERMANENT requiring further surgery to install a penile implant and/or urinary sphincter (if that's what the patient need/wants).  There is also the risk of collateral tissue damage to the rectum and/or bladder which can have other consequences.  

These are risks that NO man should have to accept if there is a better and potentially less damaging alternative.  Radiation treatment by CK or some other means would be that alternative.  It all depends on whether or not the cancer is sufficiently localized or not to justify such treatment.  BTW, the same consideration applies to surgery as well.

Good luck!

 

 

Pathfinder
Posts: 55
Joined: Jun 2016

Thank you for your input Swingshiftworker,

Yes, the ED and incontinence are the main things we're aware of and concerned about regarding surgery. Thanks for the info regarding MRSI and Cyberknife surgery. 

It feels like although we now have a lot of information available thanks to you guys, we're really just at a wall with regard to the ultimate question: is the cancer contained or isn't it. :(

As you said, CK is better for PC contained within the gland (and if we could be totally sure that's the case, I'd probably leap on the first hospital that could offer it!)

I think since the HT is in effect, and many here have said that that affords us some time, that our next step should be to seek out better imaging software wherever it can be found. We have located a Tesla 3.0 locally, and I'll add the MRSI to the search list. Even if it's in another city, it will be worth the trip. 

I think being as sure as we can as to whether the cancer is contained in the gland will help a lot, although I've heard even the very best imaging software isn't ever 100% and can still miss things.

Thanks again guys.

 

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3228
Joined: May 2012

Pathfinder,

Any decision regarding your dad's treatments is most likely pending on the T 3.0 scan outcome. While it is not perfect imaging, it is the best available. 

I am a guy who had DaVinci surgical removal, and who studied options extensively in advance. MY case was mild and incipient, very unlike your father's biopsy suggests his is.  Initially, and now, he seems to me like a patient for whom radiation would be the preferred approach.   IF the 3.0 shows capsular escape, there is no way I would allow surgery (if you are making the decisions).

The type of radiation employed would very likely be IMRT or IGRT.  Approximately 50% of all new PCa cases in the US are treated first-line with radiation, the other 50% with surgical removal.  Curative-effect rates for the two, for NON-METASTATIC disease are statistically identical.  Side-effects do vary significantly.

For disease known to be metastatic before treatments are begun, surgry is almost never suggested, even by surgeons. There are LIMITED, rare exceptions.

Investigate available radiation modalities where he is located.  Cyberknife, while wonderful for PCa in side the gland, is usually not recommended for disease that has spread, as noted.

IGRT radiation in a heavy case like his would use at least 76, and possibly as much as 80, Gray of radiation.

I have summarily listed these items for simplicty and ease of reference. Everything I have written here has been posted to you already by one or more of the guys, in narrative, paragraph form.

max

hopeful and opt...
Posts: 2218
Joined: Apr 2009

is an effective treatment for patients with a Gleason 8. Machines using SBRT are very precise and the permiter of treatment can be adjusted.

I know a man with a Gleason 8 and a high PSA who has had this treatment about a year ago. He first had a course of Lupron, a first line hormone, for a couple of months so the radiation would be more effective. He then had five sessions of Novalis, one the machines that deliver SBRT. He is continuing with Lupron now. His PSA has significantly declined

By the way he did not have an MRI

Pathfinder
Posts: 55
Joined: Jun 2016

Once again, I'm really grateful for this information guys.

Max, you've really spelled it out nicely there, very black and white, which is really helping me to understand our position, and hopeful, knowing he did radiaton without an MRI is surprising but useful!

We believe there may be a Cyberknife available locally, although this is dependent on the 3.0 MRI. I heard Cyberknife was relatively old tech - is this true, or is the best recommendation for prostate removal (in your opinion?)

Although our course of action currently is to persevere for a more detailed MRI or MRSI to be more sure about the PC containment, apparently he can't have those scans until 6 weeks post biopsy due to scarring or healing affecting the imaging results. Does this sound correct?

Secondly, and although we're definitely going to have the MRI before making a decision, our bigger concern is Chinese doctors not seeming to know much about radiation therapy! It's really bothering us, because they all seem to just say "surgery". That may be because, based on the current MRI, they believe the PC to be contained and therefore operable, but we have a sneaking suspicion that they don't commonly practice radiation for PC.

I know that sounds crazy, and we're hoping we're completely wrong. Max's suggestions of IMRT or IGRT give me something to read up on, but is there anything else we should know about modern radiation therapy that we can pursue with the local hospitals? For example, what is the latest and preferred method of radiotherapy done in the west - is it by rod, pellet, etc? We're not sure what we should be asking for.

Thanks once again!

Pathfinder
Posts: 55
Joined: Jun 2016

Before someone asked about the prostate size. Here is the best translation of the report we can manage:

"Prostate size not see definite volume increase, size 4.8cmx2.9cmx3.4cm (Transverse diameter, anteroposterior diameter, vertical diameter). Intermediate area saw small nodule T1 slightly T2 signal, DWI showed no signs of restricted diffusion, dynamic enhanced scan showed gradual strengthening; Around Prostate left rear see a nodular T1 short T2 signals, approx 1.8x1.6cm, DWI showed slightly higher signal, ADC map showed low signal"

And there are some additional comments regarding lymph nodes:

"no seen lymph node in pelvic, no liquid in pelvic, pelvic is normal"

 

 

Pathfinder
Posts: 55
Joined: Jun 2016

Today we've been given a lot of conflicting information. Many domestic people who have either had, or have had PC in their family, say that in most cases doctors in China recommend surgical removal of the gland, even when cancer has left the gland. 

The reality is that they don't seem to practice radiation therapy as much, meaning that the technology is limited.

Regarding Cyber Knife - and this is rather impressive - one of the only Hospitals in the whole of China that has Cyber Knife is right on our doorstep. That's kind of amazing, since it's a pretty big country! 

We were told that CK is usually used on brain cancer and other organs, but not so much on the prostate. I don't know if that's true, you need to remember western medical practices are certainly ahead of the game. A person whose father underwent CK surgery to remove the prostate who had cancer contained within the gland, still ended up with bone metastases later and the cancer running wild. When querying this somebody said that CK is fairly powerful and it likely didn't just destroy a portion of the cancer within the prostate, but the "good fighting cells" around the outer rim. By killing the natural defence in the tissue the cancer was inadvertantly set free. 

Does this sound possible? I know two people have used CK here with no probems, but apparently it's a method reserved for patients in an earlier stage, rather than Gleason 8.

Any information would be appreciated.

Finally, my father in-law has mentioned testicular pain the last two days. He has been on hormone therapy a week (beginning with an injection, and then daily pills) and I suggested that this was probably a side effect of the drugs affecting the testicles. He is worried it's a spreading of the cancer from the prostate to the testicular region. 

Can anyone confirm if HT will cause testicular pain?

Thank you!

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3228
Joined: May 2012

Path,

You asked a variety of questions since anyone else has written. I will respond to a few of them.  Cyberknofe is one form of SBRT radiation.  Traditionally, radiation is delivered in "fractionated " form,  meaning in comparatively low applications over a period of weeks , to even around two months. But the total number of Gr (Gray, a measure of radiation) is in the end about the same for both. IGRT is a form of very precise fractionated therapeutic radiation.  Cyberknife has benefited from very slick, professional marketing. My radiation oncologist was not a fan, although his group does SBRT as well as fractionated. But SBRT does have widespread acceptance today.

SBRT is in routine use for prostate cancer, in no sense is it new,  although overall SBRT began more forr difficult to access tumors, especially in the brain and lung.

The idea behind SBRT is to deliver the radiation in much stronger individual doses, usually doing in a week or so what otherwise might have taken two months with fractionated delivery. Added to this is extremely accurate delivery.   The efficacy of fractionated and SBRT are about the same, as determined by the long-term studies done so far, but this question is far from resolved yet.  It will be another decade or so before a definitive answer comparing the two can be derived.  It often takes decades for these sorts of data to accumulate, because radiation can have side-effects on cell health that only appear after decades.

"Cyberknife" is a proprietary, company name. Other companies also provide SBRT radiation, primarily Varian.

From the continuing issues you are having with your relative, I think I would try to take him to a Western nation, or Japan, for treatment, if that is an option. 

 

 

VascodaGama's picture
VascodaGama
Posts: 2958
Joined: Nov 2010

Testicular pain is not in the list of prime side effects from hormonal treatments but it is possible to occur, in particular, in the initial two weeks since starting LHRH agonist treatment. These agonists cause a flush in the FSH signaling which will "order" the testicles to produce testosterone continuously. From the third week on the pituitary stops the orders and the testicles enter into stoppage. The increased activity of the testis leads to increased flow of blood in local veins that could cause pain.

In any case I would strongly suggest your relative to inform his doctor on the matter and on any other symptom he will experience. Here are typical side effects from HT;

http://prostatecanceruk.org/prostate-information/living-with-prostate-cancer/how-hormone-therapy-affects-you

VG

 

Pathfinder
Posts: 55
Joined: Jun 2016

Thanks Max for that information regarding radiation treatment. We used that today when speaking to the original doctor who handled the biopsy, and he said radiation treatment was an option, which is good, but because they believe the cancer is still within the gland, surgery is still reccommended. 

Our plan is still to get the MRI again with a 3.0 machine to be more confident about that, however. 

What he didn't give us time for is to ask detailed questions regaridng radiation surgery. Time is extraordinarily limited here. If you get 10 minutes you've done well. I'm considering going abroad as per your suggestions, but that's later down the road. One step at a time.

VGama, appreciate that! To be detailed, it seems to be the right testicle that's aching. We informed the doctor today and he did an inspection of the rectum using his finger. He concluded it was an unrelated infection in the testicles and prescribed over $50 worth of medication and sent us out the door.

In my opinion it is not related to infection whatsoever and he made a nice commission on the prescription - as they do - and now my father in-law is taking meds (about 7 boxes worth) that he doesn't need. In my estimation it must be related to the HT or the PC, because that makes a lot more sense than a sudden 'testicle infection' considering the circumstances.

Which leads me to ask two pertinent questions: 

1: Is there an increased liklihood of testicle infection with PC or accompanying HT?

2: Is such testicle aching a possible sign of the cancer spreading to the area?

We're obviously very concerned about the latter.

Thank you again, your information is invaluable.

 

VascodaGama's picture
VascodaGama
Posts: 2958
Joined: Nov 2010

I understand the difficulty your relative is having in getting comments from his doctor. Urologists do not like to discuss with "educated" patients when subjected to questioning. Apart of that, hospitals are so crowded and busy that they regulate limits in the time of consultations spent with each patient.

To answer your question; I never read reports about prostate cancer metastases to the testicles. In advanced cases (I think not your relative's) prostate cancer tends to invade firstly the localized lymph nodes and from there it goes to the lungs, liver and bladder. It travels via the blood vessels so that it is caught in the lymph nodes (the filters of our circulatory system). However, even those that pass these filters do not adapt and survive that easily at the newer environment (home). These cells will be targeted by our immune system that see them as "foreigners" to that local. Unfortunately some may survive.

In any case, I have heard of guys reporting about testicle pain, ingrowing pain and lower abdomen pain, by the occasion of being diagnosed with prostate cancer, though the pain seem to be a neurologic matter. Our mind plays tricks on us and fakes us in feeling pain down there every were, with no particular reason. Even the slightest feel becomes a huge worry making us to relate it to the cancer.
As I commented before HT drugs do not cause infection or pain.

Regarding your above information on the MRI, It says that the size of the prostate is normal. They also could not verify lymph nodes involvement. But they point out about a nodule at the back left tissue surrounding the gland. Could this mean extra-capsular extensions?
This is an area out of reach for the finger touch.

I still recommend you to do the T3 MRI and get a second opinion on its results from an independent radiologist. You can do it in the USA with a copy of the MRI film. Upon that you will have the confidence in deciding to advance with surgery or radiation.

Wishing you peace of mind.

VG

  

Pathfinder
Posts: 55
Joined: Jun 2016

Brief follow up: the testicle discomfort hasn't subsided with the prescribed medication, which is exactly as I suspected - they just threw $50 worth of pills his way for the commission. 

He says he doesn't want to take them any more (and I'm wondering personally if such medication can adversely affect the HT treatment in some way) but I told him to keep on them for at least a week just in-case to see if there's any result.

A shame when doctors are also vultures, but that's the way of the world in countries with no national health services. You're a customer, not a patient.

Pathfinder
Posts: 55
Joined: Jun 2016

Hello all,

We've been busy. Seen many doctors and visited many hospitals. In the end we came to the conclusion that surgery is the right option for now. The reasons in brief:

- China's radiotherapy isn't as advanced as the west, and the radiologists aren't as experienced in treating prostate cancer. 

- In all consultations regarding the diagnosis, the case is considered to be 'mid-high risk', a T2c with a possiblity of a T3a. Because of this, and because the MRI concluded that the cancer was contained within the gland, we've decided to take a chance on surgery in the event that the cancer is actually contained, and that if not, the surgeon can clean up anything that appears outside the region. There is then an option of salvage radiotherapy later.

- We were given an option of Brachytherapy by one hospital, but they have only treated a handful of cases, and according to information obtained, Brachytherapy is more for low risk patients (and the findings of its efficacy are not conclusive yet).

The question now is what type of surgery to have. We're not sure what to do.

- There is an option in Shanghai, a surgeon with a lot of experience in open type surgery. He favours this kind because of his experience and because he feels it is more thorough than the other options. Unfortunately this is the most costly option for us (by far - 70% more expensive than a local operation). 

- There is an option for local treatment in the city's best hospital using Laparoscopic surgery (4 holes) but they only treated 8 cases of PC last year, hence, less experience in terms of case numbers. They don't offer open surgery. This option is considerably cheaper because some subsidies are available (70% cheaper than Shanghai).

I know money shouldn't really an issue, although whether we like it or not, it will certainly be an issue later. For now I was hoping to get your input regarding Laparoscopic over open surgery types. I understand the latter is less common these days, but we're worried Laparoscopic may be less thorough. 

Would you go for the open type with the experienced surgeon in Shanghai, or Laparoscopic locally in a well respected hospital, but with a lesser case history?

Do cleanup results usually vary a lot between these two surgery types?

Thank you for your advice! 

 

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3228
Joined: May 2012

Pathfinder,

I will give opinions on several of the questions you posited.

First, while radiation therapy is often a better choice, if current, advanced deliveries of radiation are not available, then indeed it comes off the table as a good option.

You are correct that Brach ("seeding") is usually reserved for mild cases. I cannot imagine that he is such a case.

In the US for surgical removal of PCa, DaVinci Robotic is now the most common, but open incision is not uncommon.  DaVinci is a form of laproscopic, but I am not versed in non-DaVinci laproscopic technology for RP, and can't comment.

If the open-incision doctor is "a lot more experienced," that is what I would go with.  Open-incision is still a technique of choice even in the US for complex and problematic surgeries, and makes "node mining" (checking sentintal nodes for involvement) much easier.  Dr. Peter Scardino, Chief of Surgery at Sloan-Kettering Cancer Center in NYC, himself prefers open incision.

I had DaVinci removal myself, 1.5 years ago.  Open-incision surgery is reportedly slower to recover from, but it seems other issues in his case are more determinitive than recovery time or ease.

Regardless of method used, demand that the seminal vesicles be removed.  This is universal now in the US, and there is virtually never a reason to not remove them.

Liker the other guys, I am not a doctor, and have no medical training whatsoever.  We relate opinions, not medical advice.

I hope this is of assistance,

max

Old Salt
Posts: 720
Joined: Aug 2014

Here in the US, it is generally agreed that a surgeon needs to do at least 100 procedures (open, laparoscopic, or DaVinci) to become expert. Therefore, I also recommend the Shanghai (open surgery) option. Recovery will take longer, unfortunately. On the other hand, open surgery gives the surgeon a few options that are unavailable otherwise.

Just like Max, I am not an MD, but  I have read quite a bit about prostate cancer, as a patient.

VascodaGama's picture
VascodaGama
Posts: 2958
Joined: Nov 2010

I did open surgery 16 years ago, so that I would recommend open instead of the laparoscopic. Both are good but the experience of the surgeon should be the subject to consider in the decision. Open takes longer to perform but the doctor can disect lymph nodes at the iliac which is proper when we have no conclusive image study.  Laparoscopic has lesser cutting therefore faster healing with shorter period of staying in the hospital (cheaper therefore) but the important in the treatment is the outcome, so that the facilities, experience of physicians and after care are important matters to consider.

Best,

VG

Pathfinder
Posts: 55
Joined: Jun 2016

Just to say thank you all for the responses, it's been extremely helpful in making our decisions. At the moment we're trying to work out some kind of possible subsidy for the cost of the surgery. It's unlikley but worth a shot. My father in law is just now month 2 of diagnosis and is getting the second HT injection and more pills today, but we're hoping to get the surgery done ASAP. 

Will update ASAP. 

Will Doran
Posts: 207
Joined: Sep 2015

Pathfinder,

As I have stated, I was a PSA of 69 with a Gleason 7, when diagnosed.  According to my MRI's the cancer was confined to the gland. So, surgery was my best option at the time (3 years ago-next week). So, I , like Max, had DaVinci assisted surgery.  The surgery took 5 1/2 hours becasue of a birth defect and complications caused by a double abdominal hernia rerpair.  I was home the next day after the 5 1/2 hours of surgery.  Back on a treadmill in three days and back on my spinner bike in 6 weeks (two weeks ahead of what I was told to expect).  As VG said, the recovery is much faster from the Robotic assisted surgery.  I didn't even have stitches on the outside.  My surgeon is a firm believer in using some kind of glue.  Not sure what it is called.  But there was no follow up stitch removal.  I had some incontinence problems at first, but that is improving.  I was an Aggressive Stage 3, but was treated as a Stage 4, because in the followup Pathology I had one very small spot in one lymph node.  As Max said, demand that the seminal vesicles be removed. That was done in my surgery and all was well.  It was good to get that report back.  So, I was started on, follow up, with 2 years of Lupron.   And,  then after the Lupron was started first,  8 weeks of RT.  My doctors told me they were going to be very aggresive and they were.  So, far that has all worked out OK in my case.  Like Max and Old Salt have said, I am not an MD.  I can only tell you what has worked in my case.  Our cases are all different. 

In an earlier post from you, you mentioned that your Father-in-law was experiencing testicular pain when he started Lupron.  I had that as well.  I was told that that might happen, because the Lupron causes the testicles to kick into "high gear"(my doctors words) at first and that pain can happen.  Right now, after I've been off the Lupron for 5 months, at this point, My Testosterone is coming back up.  It's still low and I still have a few hot flashes, but my "T" level has come up from 17 to 134 as of my last blood work. Normal is 250 - 1,000.  At this point I am having some testicular pain again as they are starting to function again.  I have more blood work in two weeks and will have my check up and will ask about this at that time.  My doctor told me at my last check up that, again, this pain might occur.  My doctors have been very good at warning me ahead of time of what to expect, all the side effects, etc. 

Best of luck

Tell your Father-in-law, to be strong and fight like the devil

Peace and God Bless

Will

Pathfinder
Posts: 55
Joined: Jun 2016

Surgery completed this morning. It was open surgery performed in Shanghai.

At the moment my Father in law is doing ok. Still sleepy from anaesthetic. The doctor said his heart rate has been a bit low all day. We're not sure why that is, although nobody is treating it as a cause for concern at the moment. I'm assuming it's due to such a heavy surgery/blood loss.

We literally only had 30 seconds to ask one of the surgeons some questions, so unfortunately we didn't get much information and will probably need to wait until tomorrow for more details. 

We know that the seminal vesicles and lymph nodes were removed and there was no sign of metastases there, they surgeon said they were ok. 

They did say that there was some adhesion around the prostate due to 6 weeks of hormone therapy. And that's all he said. He didn't say if it was a complication or problematic for the future, so we're left wondering what that means for us and googling various info (and not finding much).

I understand HT can create adhesion around the prostate gland which can make it more difficult to cut. I'm worried the adhesion may make it difficult to cut any infected areas.

I have no idea why the initial hospital put my father in-law on HT for 3 months (of which he only completed 6 weeks due to us speeding up the surgery process) if there is the potential for adhesions like this?

Perhaps we're over-worrying on this, the doctor really only mentioned it briefly. But I'd appreciate your knowledge about this because there's very little I can find on the net.

Thanks guys!

VascodaGama's picture
VascodaGama
Posts: 2958
Joined: Nov 2010

The majority of surgeons in open surgeries do not like that feeling of sticky fingers. They do the cutting using the touch and vision trying to separate the gland without inflicting any injury to attached tissues. That glue like aspect caused by HT confuses the touch, in particular if any bump exists which would be targeted for dissecting. The worry is if the outer shell of the gland is cut freeing cancerous cells that could be glued to that sticky coat and left behind. Please read my comment above in regards to the negative of HT before RP.

This is just an added worried because the surgeon will vacuum the whole area carefully sucking the blood and any detritus before stitching up.
in regards to the doctor’s comment on the seminal vesicles and lymph nodes, that is an impression regarding the aspect these presented. Cancer cannot be seen by the open eye unless it is a sizable tumour. Typical affected lymph nodes present sort of bumps that could be made of small tumors or just blood detritus.

The gland including those lymph nodes and seminal vesicles, etc, will be sliced and analyzed under the microscopy by the pathologist that will inform on the findings. Hopefully they find no extra capsular extensions which would lead the outcome of surgery to the highest points. Unfortunately, HT will also prejudice a complete answer on the outcomes because it will mask the PSA, making it impossible of providing proper result and indication on remission. Your father in law will have to wait til the end of the effect of HT to get that ultimate answer. Remission status.

Best wishes and luck.

VGama 

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3228
Joined: May 2012

I'm glad his surgery went well and is now over, Pathfinder.

The meeting with a surgeon following a surgery is ordinarily brief even in the US, because the doctor is usually on his way to prep for his next proceedure. My RP surgeon has "surgery day" twice a month or more often, in which he is in the O.R. basically all day long.

As Vasco explained, knowing the results of the surgery is essentially a case of getting the Pathologist's Report and the Surgical Summary. These are of course DIFFERENT reports.  Language issues permitting, get PAPER COPIES of both of these, even if they have to be in Chinese. If you do not read Chinese yourself, you can have them translated later.  They will probably not be available for a few days, but if you don't get them soon, they will be much harder to track down later.

As Vasco also noted, a surgeon cannot ordinarily "see" cancer, unless the tumor is sizable or there is overt tissue differentiation.  But only the pathologist's analysis gives definitive information.  While there are positives and negatives for surgery vs. radiation, one real advantage of surgery is that after the gland is on the lab table and under a microscope, the doctors can know EXACTLY what they were dealing with, At that point, imaging is irrelevant.

He will wear a cath about a week for the uretheral reattachment to heal.

Following surgical removal, if all cancer was removed, PSA drops to "undetectable" within a few weeks.  AS Vasco in addition noted, though, the HT in his case will mean that 0 PSA readings could be partially the result of the HT. Therefore concluding that undetectable PSA results are not HT-related will not be certain until the effects of the HT has cleared his body.

Good luck and negative reports to the both of you,

 

max

Pathfinder
Posts: 55
Joined: Jun 2016

Thanks for your swift reply. 

Yes, so I'm somewhat unsure why the initial hospital suggested 3 months HT prior to surgery. Is this way off standard procedure in the west? Is there any good reason why they would have suggested this course of treatment before surgery? I did recall your comments previously regarding this.

At the moment we're yet to get the details about the actual condition. Of course we need to wait for the pathology report, and that will take a while. As you said, the HT will need to wear off for an accurate PSA result, and we're not sure how long he should suspend it for. We'll ask the surgeon as soon as we have a chance.

Appreciate your input.

Will Doran
Posts: 207
Joined: Sep 2015

Pathfinder,

Glad your father-in-law's surgery is completed.  I had an adhesion (prostate to bladder), when they did my surgery.  However, it wasn't from the HT.  I never had HT until  post surgery.  My adhesion was a birth defect.  It did slow down the robotic assisted surgery quite a bit, plus some other complications from a double abdominal hernia repair, and extreme leg muscle development from road cycling..  The surgery was supposed to take 2 1/2 hours and ended up taking 5 1/2 hours.  I also had no metastases in seminal vesicles but did have a small spot in one lymph node.  Thus I was treated as  Stage 4.  I am , as of this past week a three year survivor, from the time of diagnosis. At my last appointment with my surgeon/urologist he is talking 10 years from now. I will see him in four weeks for my next checkup and will know more at that time.    I would suspect your Father-in-Law will have radiation after some recovery time, as a "clean up".  That's what they did with me, and it worked out well, so far.    So keep the faith.  The wait for all the reports seems to take forever, I know.  But hang in there.

As Max & Vasco said, The HT will keep the PSA at "0".  the complete resulte won't be know until the Ht wears off.  I had two years of HT, post surgery, and that has been finished for 6 months at this point.  At my last check up I was still a PSA of <0.010.  My next checkup in a months time will tell us even more.  Your F-i-L's PSA should go down quickly, post surgery.  Mine went from pre surgery  69  down to .6 in two months before I started HT and Radiation.  Then went to "0" and has stayed there for three years.  It's amazing what they accomplish with us.

Know that you all are in my thoughs and prayers.

Peace and God Bless

Will

Pathfinder
Posts: 55
Joined: Jun 2016

Thank you Will for sharing your story and those encouraging words! The pathology report does indeed seem to take its time. That the seminal vesicles and lymph nodes appeared fine is the most encouraging news we got from the surgeon - at least we know the checkup (despite the lesser technology) was right about no bone metastases, it's just a case now of finding out if the cancer was indeed contained within the gland.

I just want to share a story with you all for future googlers and people with this condition: My father in law shared a room with a 72 year old man with PC who had just completed open surgery to remove the prostate.

10 years earlier this man had a PSA of 5, and subsequently ignored it for a decade. The PSA rose steadily over the ten years, until eventually they went to see someone. He had a PSA of 54 and was biopsied as a Gleason 9. 

When he got his post surgery pathology report back, they found that the cancer had never left the gland, never affected the lymph nodes or bones, and he's perfectly happy and well. 

It was quite an amazing story that shows there are certainly no guarantees with PC or any cancer - although I certainly would never recommend anyone ignoring a high PSA for a decade!

Thanks again for all your patience and help.

Pathfinder
Posts: 55
Joined: Jun 2016

I'm looking for advice regarding when HT should be resumed post surgery? I've searched the internet but can't find much info except that HT post surgery can prolong life expectancy.

Currently my Father in Law has suspended the HT since just prior to surgery until now (so about 4 days). I found this article regarding the pros and cons of NAD in PC treatment, but there's not much about when it should be continued post surgery (if at all?)

http://emedicine.medscape.com/article/455994-overview

Any ideas about this would be much appreciated, thanks!

Old Salt
Posts: 720
Joined: Aug 2014

Let's wait for the pathology report. If it shows that cancer was very close to the edge of the prostate, the chance of cells having escaped the prostate is greater. In that scenario, hormone treatment might be considered.

I would also want to see a PSA post surgery before making such a decision.

Pathfinder
Posts: 55
Joined: Jun 2016

Old Salt, but he was on HT prior to surgery for almost 2 months - will that affect the pathology report? Studies show HT prior to RP can affect the pahtology report. He's only been off of HT four days or therabouts. 

How long will it be before we can get an accurate pathology report or PSA? Some literature suggests to continue HT directly after surgery. We're not sure how long is safe to wait.

Thanks for your help!

Pathfinder
Posts: 55
Joined: Jun 2016

Pathologic report: Gleason 4+4=8,Neural invasion, invasion to the capsule, but no break through; no seminal vesicle invasion.
Immunohistochemistry Results: 
Tumor cells PSA (+), P504S (+), PSMA (+), PSAP (+), P501S (+), AR (+++), CK20 (-)., Ki67 (+ 1%) 
Basal cell p63 (-), 34bE12 (-), CK5 / 6 (-).

The pathology report is in. Apparently there is some controversy about when or whether or commence HT after surgery. Can you please give us your advice regarding this?

The details and pathology report are as follows:

Pathologic report: Gleason 4+4=8,Neural invasion, invasion to the capsule, but no break through; no seminal vesicle invasion.
Immunohistochemistry Results: 
Tumor cells PSA (+), P504S (+), PSMA (+), PSAP (+), P501S (+), AR (+++), CK20 (-)., Ki67 (+ 1%) 
Basal cell p63 (-), 34bE12 (-), CK5 / 6 (-).

Prior to Surgery, was given hormonal therapy for 1.5 months, doc said there's adhesions during surgery due to hormone therapy.  Also said pathologic report might not be accurate coz of HT before surgery.

Now 8 days after surgery, doc suggests go back on HT for at least 9 months.

Thank you for your help!

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